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Division of Cardiothoracic Surgery, St. Louis University, 3635 Vista, St Louis, MO 63110
(Email: hbarner{at}slu.edu).
There are enthusiasts for gastroepiploic artery (GEA) coronary bypass grafting on three continents, and a few surgeons have reported large experiences using this conduit, but 10-year patency is disappointing. Early patency of the free GEA has also been inferior, but the experience is small and early in the use of this conduit (ie, 3 of 4 reports from 1990 or before and 1 of 4 from 1993).
The GEA graft has been attractive as an in situ conduit and used by some to achieve all arterial revascularization without aortic anastomosis when combined with the in situ internal thoracic arteries (ITAs). Despite this utility, there are several limitations and concerns.
The GEA is less consistent in size than the ITA and the radial artery (RA), and its in-flow via the celiac axis may be compromised by atherosclerosis. The GEA also diminishes in diameter along its length to a greater degree than the ITA or RA, so that its useful length may be limited. Routing through the diaphragm is relatively straightforward and has not been identified as a cause of failure, but it does present the concern of angulation or kinking and the challenge of optimal placement to achieve a parallel approach to the target without compromising conduit length. Having a totally muscular media, such as the RA, it is more prone to spasm than the ITA, will usually benefit from topical or intraluminal vasodilators, or both, and it is vulnerable to competitive coronary flow. Also subsequent laparotomy may result in injury to the conduit. Initial harvesting was done with a bulky pedicle of omentum with a subsequent trend toward semi or true skeletonization, which is more attractive. The present report uses a free graft with a bulky pedicle and anastomosis of the gastroepiploic vein to the right atrial appendage. Most impressive is the 95.7% patency at a mean of 77 months in 46 patients. I believe the improved patency is a consequence of good surgical technique and free grafting that improves in-flow and addresses many of the previously mentioned concerns.
The authors [1] suggest that venous drainage is the reason for improved patency, but they do not provide a control group. Historically, it has been suggested that the free ITA graft would be compromised without venous anastomosis but patency for it, the RA and the inferior epigastric artery disprove that viewpoint.
The authors experience warrants consideration of preferential use of the GEA as a free graft from the aorta or the ITA without venous anastomosis and with a lean pedicle or skeletonized conduit.
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